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11-98-1999 10: 11AM FROM P. 4 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHO) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin county for a Permit to construct andlor install the work described. This application is made in compliance with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division, <br /> r /I '' Assessors <br /> WELL Location (050 Sctyi, Imo..—QJ 5} 43ark{„�, cross street arc{u,,,f; Sy city %acK7'o�n 7Jp FS2oi Parcel# <br /> PROPERTY Owner )�l(4,1 J C- T- MeressILK0 SC."'�n�.�-..•+d S+.rrf city �k-)a•, Zp2jE01 Phone# ZOc)-497.eCVO <br /> CG57Conuactor 9vv g �n'I�M�,�Tz,I+� Address `ASO Le 121 City nt_V z =p9�73 Lilt PhoneM rl2S'313-Sb'Lt0 <br /> Consultant l Sub Contractor Ale /'KSe1.AL f Address III-; L,e R4--Ale %9 City fl.d Lies—Phone],2dt-7 7G-zz21 <br /> GIS Coordinates:X , Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> ) NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH.HAND-AUGER,OTHER-) Q DESTRUCTION(choose type babW) <br /> Q SOIL BORING N U OVER-BORE <br /> •00wr: XMELL C MW 9 p PRESSURE GROUT <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATO)h& <br /> MONITORING Q HOLLOW STEM DIA. OF BOREHOLE YI' MULTIPI 9 CASINGS?0 YES YNO WELL CASING DIA; 2'1 <br /> Q EXTRAC ON aAIR HAMMER/ORIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL )KPVC U OTHER. <br /> Q VAPOR *U0 ROTARY DEPTH OF GROUT SEAL 97' TREMIE TYPE TO BE USED: p AUGEP.S UHOSE <br /> Q AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: Q Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH 1S 30) <br /> 0 SOIL BORING 11 HAND AUGER APPROX. BORING DEPTH 11 2' BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q OTHER: D CTHER CONDUCTOR CASING PROPOSED? (ifYES.list speahcations here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby cemtythat I have prepared this application and that Ne work will be conein accordancewith San Joaquin County rlinancers,State Laws,and Rulas <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following; "I certify that In the performance ofthe work <br /> for which this pomit Is Issued.l shaft not employ parsons subject to WORKERS'COMPENSATION Laws of California." Conractor's Nring or sub- <br /> contracting signature certifies the following; 7 Wn ly that in the performance of rhe work for which this permit is`ssuad, I shell employ persons subject to <br /> WORKERS'COMPENSATION Laws ofCalitomia.- <br /> THE APPLICANT M.J8T GALL m WORKING HRS IN 4bVANCE FOR ALL.REaUIREDINSPECTIONS. <br /> Signed /S40:5 <br /> SEE SIYE MAP IN UNIT IV WORK PLAN DATED: I- -03 <br /> �n DEPARTMENT USE ONLY <br /> /7/ <br /> Application Accepted By _ Date Issued a t 3' Area y <br /> Grout Inspection By /K , ":ir - Date 4 Final Inspectlon Byte <br /> Destruction Inspection By Data CRIAMLETEM <br /> COMMENTS/CONDITIONS <br /> ACCOUNTING ONLY: AID# <br /> PACA <br /> PE CODES FEE INFO I AMOUNT REMITTED CHECK# i DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a,To i 'i I 9 7 35 y <br /> C-57 LICENSED CONTRACTORMUSE SIGN LICENSE&.WORKERS'COMPENSATION.DECI—kR\TION <br /> UNIT Iv-6/23/99/sign bkpg/MI -- - <br />